HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD �F EALTGH
1J1�%ll....................OF....................1�IT>U!��1.-..................................
Appliratinn for 14spas .oaks Tonsir7an
iu raftttt
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
System at • _
....... s: -- �►�/- '�...........................................................1�1�C�__g��..-• ------........---
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�� tc!!h p --Address
J T J
% �{ �l{� e J� e6e _ .t address
• F �-.4 !. �!..�......................................................... ........... _ /V ���/
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ...................... I ..................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ......... .................. No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures--------------------------------•-----------•-----.-•-----•---•----------...-----------•----...
Design Flow .................................... ...... ga ns per person per day. Total daily flow --------------------------
- ................ .gallons.
Septic Tank — Liquid capacity. _ ___....gall ns Length ................ Width ............ _... Diameter______-_.._--_- Depth ................
Disposal Trench — No ........... ....... Widt -----------------
Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No. meter...._._. __...._.._. Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Do ing tank ( )
Percolation Test Results Performed by ................................................
Test Pit No. 1................minutes per inch Depth of Test Pit-. ........
Test Pit No. 2................minutes per inch Depth of Test Pit ..........
Description of Soil..
-------------- Date ........................................
Depth to ground water ........................
Depth to ground water ........................
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Nature of Repairs or Alterations —Answer when applica.ble.._�2.................._____._t�__t%..___.__..._....._.. �.__.__._....__.__.....___:
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLF, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeenI issued Ahe board of health. s
Signed.:-----'...---------------------------------------------------------- Ca ...--------
ApplicationApproved By ............... Lk'--------------•-----------.....-----------•------------•---------------..................................
Date
Application Disapproved for the following reasons: ................................................................................................................
.......................................•--------......-----------•--......------.........-•.....-----------------....------------•-----....... --•------------------
Permit No ..... � �j�-•----••---•------_. Issued.. ----
Date ._.._......
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THE COMMONWEALTH OF MASSACHUSETTS
f - BOARD OF HEALTH
�1.................OF..... .l !ff • rlfG .r...� ........................................
Tnfifiratr of Toutpliattrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (U'j
by. G`. .1/ . .......... -------------- ------ ......................-------- ......_.._...-------
r, /1_ Installer
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
1 dated---- _= = '
application for Disposal Works Construction Permit No.._. __.______ `. ' - ..•.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA GUARANTEE THAT THE
SYSTEM WILL UNCTION SATISFACTORY.
DATE.....!f. ..----• . -•-----;F........................................... .Inspector-.. Z` ---------
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